- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,691.53
| Facility | | $1,949.84 | $1,949.84 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,318.26 / $1,949.84
| Professional | | $1,023.29 | $1,318.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $2,089.30
| Professional | | $1,584.89 | $1,584.89 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,995.26 / $2,884.03
| Facility | | $1,000.00 | $1,995.26 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,548.82
| Facility | | $1,380.38 | $1,380.38 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $1,548.82
| Professional | | $645.65 | $912.01 | $1,548.82 |